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Zoster (shingles)

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Zoster (shingles)
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Note: In July 2020, Merck discontinued the sale of Zostavax (live zoster vaccine) in the United States. The latest expiration date of remaining doses is November 2020.
What is the cause of herpes zoster (shingles)?
Herpes zoster is a painful rash that occurs along one or more dermatomes. Zoster is caused by reactivation of latent varicella zoster virus infection from a prior chickenpox infection. People who have had a prior infection with varicella zoster virus (chickenpox) are at risk of shingles.
How common is herpes zoster (shingles)?
During their lifetime about 30% of Americans will develop herpes zoster, which translates into an estimated 1 million cases each year in this country. The risk of zoster increases with increasing age; about half of all cases occur among people age 60 years or older. People who are immunosuppressed, including those with leukemia, lymphoma, and human immunodeficiency virus (HIV) infection, and people who receive immunosuppressive drugs, such as steroids and cancer chemotherapy, also are at greater risk of zoster. Most people have only one episode of shingles. The risk of recurrence is low in people who are not immunosuppressed, but the precise incidence is unknown.
Can you catch zoster from a person with active zoster infection?
Zoster is caused by reactivation of a latent varicella virus infection (from having chickenpox in the past). Zoster is not passed from one person to another through exposure to another person with zoster. However, if a person who is susceptible to chickenpox (i.e., they had never had chickenpox and were not vaccinated against chickenpox) comes in direct contact with a person with a zoster rash, the virus could be transmitted to the susceptible person. The exposed person would develop chickenpox, not zoster. Covering the zoster rash reduces the chances of transmitting varicella zoster virus.
For our "Mother's Day Out" program, one of the teachers has shingles. The program serves moms of 2-month-olds to 4-year-olds. All children are up to date with their vaccinations, but some are too young to have received varicella vaccine. Is it safe for the teacher to work?
In a school setting, an immunocompetent person with zoster (staff or students) can remain at school as long as the lesions can be completely covered. People with zoster should be careful about personal hygiene, wash their hands after touching their lesions, and avoid close contact with others. If the lesions cannot be completely covered and close contact avoided, the person should be excluded from the school setting until the zoster lesions have crusted over. See www.cdc.gov/chickenpox/outbreaks/manual.html for more information. If your program is licensed by a state or county, you should check their regulations as well.
Should healthcare personnel in long-term care facilities be tested to see if they have had chickenpox before taking care of someone who has shingles?
All healthcare personnel should ensure they are immune to varicella regardless of the setting in which they work. For healthcare personnel, accepted evidence of varicella immunity includes any of the following: 1) documentation of age-appropriate vaccination with a varicella vaccine, 2) laboratory evidence of immunity or laboratory confirmation of disease; 3) diagnosis or verification of a history of varicella disease by a health-care provider; or 4) diagnosis or verification of a history of herpes zoster by a health-care provider.
Vaccine Recommendations Back to top
What zoster vaccines are available in the United States?
Recombinant zoster vaccine (RZV, Shingrix, GlaxoSmithKline) was licensed by the Food and Drug Administration (FDA) in October 2017. It is a subunit vaccine that contains recombinant varicella zoster virus (VZV) glycoprotein E in combination with a novel adjuvant (AS01B). Shingrix does not contain live VZV. It is FDA-approved and recommended by the Advisory Committee on Immunization Practices (ACIP) for people 50 years and older. Shingrix is administered as a 2-dose series by the intramuscular route. The second dose should be given 2 to 6 months after the first dose.
Zoster vaccine live (ZVL, Zostavax, Merck) is a live attenuated vaccine that was licensed by the FDA in 2006 for adults age 50 and older and recommended by ACIP for people age 60 and older. It is administered as a single dose by the subcutaneous route. In July 2020 Merck discontinued the sale of Zostavax in the United States; the latest expiration date of remaining doses is November 2020.
How effective are zoster vaccines?
Shingrix was studied in 2 pre-licensure clinical trials. Efficacy against shingles was 97% for persons 50–59 years of age, 97% for persons 60–69 years of age, and 91% for persons 70 years and older. Among people 70 years and older vaccine efficacy was 85% four years after vaccination.
In clinical trials Zostavax recipients age 50 and older had a 51% overall reduction in shingles and less severe illness when shingles did occur compared with placebo recipients. Its efficacy was lower in older age groups. Protection against shingles declined over time after vaccination. By 6 years after vaccination protection declined to less than 35% overall.
Will administering zoster vaccine prevent postherpetic neuralgia (PHN)?
Yes. In clinical trials, Shingrix reduced the risk of PHN by 91%.
To whom should zoster vaccine be given?
ACIP published its most recent zoster vaccination recommendations in January 2018, available at www.cdc.gov/mmwr/volumes/67/wr/pdfs/mm6703a5-H.pdf. Its key recommendations are listed below.
  • Shingrix is recommended for the prevention of herpes zoster and related complications for immunocompetent adults 50 years of age and older.
  • Shingrix is recommended for the prevention of herpes zoster and related complications for immunocompetent adults who previously received Zostavax.
  • Zostavax remains a recommended vaccine for prevention of herpes zoster and its complications in immunocompetent adults 60 years of age and older. However, Shingrix is preferred. [Note: Zostavax was withdrawn from the U.S. market in July 2020].
My clinic cannot consistently keep Shingrix in stock due to high demand. How should we handle challenges ensuring patients receive a second dose?
Clinicians and patients should make every effort to ensure that two doses of Shingrix are administered within the recommended interval of 2 to 6 months. If more than 6 months have elapsed since the first dose of Shingrix, administer the second dose when possible. Do not restart the vaccine series. If you are out of Shingrix and a patient needs a second dose, the Vaccine Finder, sponsored by CDC and other partner organizations, may be helpful for patients to locate other providers that have Shingrix in stock. The Vaccine Finder can be accessed at www.vaccinefinder.org/find-vaccine or on the CDC website at www.cdc.gov/vaccines/vpd/shingles/public/shingrix/index.html.
Additional information for clinicians about Shingrix is available on the CDC website at www.cdc.gov/vaccines/vpd/shingles/hcp/index.html.
Should Shingrix be given to people who have already received Zostavax? If so what interval should separate them?
Yes. ACIP recommends that people who previously received Zostavax receive 2 doses of Shingrix. The first dose of Shingrix may be given at least 2 months after Zostavax.
What is the minimum interval between doses of Shingrix?
The recommended interval between Shingrix doses is 2 to 6 months. The minimum interval between doses of Shingrix is 4 weeks. If the second dose is given less than 4 weeks after the first dose the second dose should be repeated at least 8 weeks after the invalid dose.
What is the minimum age for administering Shingrix?
The recommended and minimum age for Shingrix is 50 years. However, if a dose is inadvertently administered to an adult 18 through 49 years of age CDC does not recommend repeating the dose. The second Shingrix dose should not be administered until the 50th birthday. This guidance does not appear in the most recent zoster ACIP statement but is in the General Best Practices Guidance (Table 3-1 in the Timing and Spacing of Immunobiologics section at www.cdc.gov/vaccines/hcp/acip-recs/general-recs/timing.html) and is based on guidance from CDC's zoster subject matter experts.
If the second dose of Shingrix is delayed more than 6 months after the first dose do I need to restart the series?
No. The vaccine series need not be restarted if more than 6 months have elapsed since the first dose.
Is there an upper age limit for receipt of zoster vaccine?
If a patient received dose #1 of varicella vaccine (Varivax, Merck) at age 60 years, should we administer zoster vaccine as dose #2?
The action taken depends on why varicella vaccine was given in the first place. If it was given because the person tested negative for varicella antibody, then the next dose should be varicella vaccine. If the varicella vaccine was given in error (i.e., without serologic testing), then Shingrix should be given.
Should a person who received 2 doses of varicella vaccine be vaccinated with Shingrix when they turn 50?
In its 2018 zoster vaccine recommendations, the Advisory Committee on Immunization Practices (ACIP) states that Shingrix may be used in adults age 50 years or older irrespective of prior receipt of varicella vaccine or live zoster vaccine (Zostavax).
Before administering Shingrix is it necessary to ask if the person has ever had chickenpox or shingles?
No. All people age 50 years or older-whether they have a history of chickenpox or shingles or not-should be given Shingrix unless they have a medical contraindication to vaccination (described below). It also is not necessary to test for varicella antibody prior to or after giving the vaccine.
Should people who haven't had chickenpox be vaccinated with zoster vaccine?
Serologic studies indicate that almost everyone born in the United States before 1980 has had chickenpox even though many cannot recall having had chickenpox (www.cdc.gov/mmwr/preview/mmwrhtml/rr5705a1.htm.) As a result, there is no need to ask people age 50 years and older for their varicella disease history or to perform a laboratory test for serologic evidence of prior varicella disease. A person age 50 years or older who has no medical contraindications is eligible for Shingrix regardless of their memory of having had chickenpox.
Can someone who has experienced an episode of shingles be vaccinated with zoster vaccine?
Yes. Adults with a history of herpes zoster should receive Shingrix. If a person is experiencing an episode of zoster, vaccination should be delayed until the acute phase of the illness is over and symptoms abate.
If a person was exposed to shingles by a spouse within the last few days, is there a recommended waiting period before the exposed person can receive zoster vaccine?
There is no waiting period in such a situation. Shingrix can be given right away or at any time to any person for whom the vaccine is recommended. Shingles is not caused by exposure to another person with shingles. However, exposure to someone with shingles can possibly cause chickenpox in a person with no immunity to varicella zoster virus (VZV) from either vaccination or prior chickenpox infection. Zoster is caused by the reactivation of VZV in people who have already had a prior VZV infection.
A 33-year-old patient in my practice has already suffered from three episodes of shingles. He would like to receive Shingrix. Is this a good idea?
ACIP does not have a recommendation to administer zoster vaccine to people younger than 50 years with recurrent zoster episodes. However, clinicians may choose to administer a vaccine off-label, if in their clinical judgment, they think the vaccine is indicated. The patient should be informed that the use is off-label, and that the safety and efficacy of the vaccine has not been tested in people younger than 50.
We have an 18-year-old male who had a history of chickenpox disease. He now has shingles. We are unsure what we are to advise for future treatment. Should we administer zoster vaccine?
The Advisory Committee on Immunization Practice (ACIP) does not recommend zoster vaccination for people younger than age 50 years regardless of their history of shingles.
Can zoster vaccine be administered to people in long-term care facilities?
Yes. Shingrix can be administered to anyone age 50 years and older regardless of where they reside, unless they have a contraindication to vaccination.
Can I give our long-term care residents zoster vaccine, injectable influenza, and pneumococcal vaccines on the same day?
Yes. CDC's General Best Practice Guidelines for Immunization advise that non-live vaccines, such as Shingrix, can be administered concomitantly, at different anatomic sites, with any other live or non-live vaccine. They should be given as separate injections, not combined in the same syringe.
We know that documented receipt of Zostavax in the absence of other criteria is not proof of immunity to varicella. Is this true for Shingrix as well?
Yes. Documented receipt of Shingrix cannot be used as proof of immunity to varicella. Additionally, a dose of Shingrix cannot be counted as a dose of varicella vaccine.
Can I give Shingrix at the same time as a tuberculin skin test?
Yes. Shingrix is not a live virus vaccine and does not interfere with the tuberculin skin test (TST): it may be administered any time before or after a TST. Administration of a live virus vaccine can interfere with a tuberculin skin test (TST). If the TST is not administered on the same day as a live virus vaccine, the TST should be delayed until 46 weeks after the vaccination.
Vaccine Safety Back to top
What adverse reactions have been reported with Shingrix?
In pre-licensure clinical trials of Shingrix the most common adverse reactions were pain at the injection site (78%), myalgia (45%), and fatigue (45%). Any grade 3 adverse event (reactions related to vaccination which were severe enough to prevent normal activities) was reported in 17% of vaccine recipients compared with 3% of placebo recipients. Grade 3 injection-site reactions (pain, redness, and swelling) were reported by 9% of vaccine recipients, compared with 0.3% of placebo recipients. Grade 3 solicited systemic events (myalgia, fatigue, headache, shivering, fever, and gastrointestinal symptoms) were reported by 11% of vaccine recipients and 2.4% of placebo recipients. The occurrence of local grade 3 reactions did not differ by vaccine dose. However systemic grade 3 reactions were reported more frequently after dose 2.
Rates of serious adverse events (an undesirable experience associated with the vaccine that results in death, hospitalization, disability or requires medical or surgical intervention to prevent a serious outcome) were similar in vaccine and placebo groups.
What should I advise my patients about adverse reactions after Shingrix?
Before vaccination, providers should counsel Shingrix recipients about common expected systemic and local adverse reactions (described above). Reactions to the first dose do not strongly predict reactions to the second dose. Shingrix recipients should be encouraged to complete the series even if they experienced a grade 3 reaction to the first dose.
Can the Shingrix vaccine cause shingles?
No. Shingrix contains only a small part of the herpes zoster virus and does not contain any live herpes zoster virus.
Contraindications and Precautions Back to top
What are the contraindications and precautions to Shingrix?
The only contraindication is a severe allergic reaction to a vaccine component or following a prior dose. The only precaution is the presence of a moderate or severe acute illness, including herpes zoster. In that situation, vaccination should be deferred until the illness improves.
There are no available data to establish whether Shingrix is safe in pregnant or lactating women and there is currently no ACIP recommendation for Shingrix use in this population. Consider delaying vaccination with Shingrix in such circumstances.
If an adult age 50 or older has had zoster with postherpetic neuralgia or ophthalmic complications, when can they receive zoster vaccine?
Once they are no longer acutely ill, they can be vaccinated with Shingrix. There is no evidence that vaccine will have therapeutic effect for a person with existing zoster or postherpetic neuralgia.
How long should we wait before giving zoster vaccine to a patient who has had a blood transfusion?
There is no waiting period for administering Shingrix following transfusion. Shingrix contains no live virus so may be given at any time after receipt of a blood product.
Should zoster vaccine be given to a person who is currently receiving immunosuppressive treatment?
ACIP recommends the use of Shingrix in people age 50 or older taking low-dose immunosuppressive therapy (less than 20 mg/day of prednisone or equivalent or using inhaled or topical steroids), or low doses of methotrexate, azathioprine, or 6-mercaptopurine.
Immunosuppression is not included as a contraindication in the manufacturers' package insert. However, immunocompromised people and those on moderate to high doses of immunosuppressive therapy were excluded from the clinical efficacy studies so data were lacking on efficacy and safety in this group at the time of licensure. ACIP has not yet made a recommendation regarding the use of Shingrix in these patients, but is anticipated to do so in the future.
I have a patient who is eligible for zoster vaccination who is going to be receiving chemotherapy soon. What are the guidelines in such a situation?
The risk for zoster and its severe morbidity and mortality is much greater for immunosuppressed people. A 2-dose series of Shingrix should be administered as soon as possible while the person's immune system is intact.
When can a patient previously on immunosuppressive chemotherapy receive zoster vaccine?
ACIP has not specifically addressed the use of Shingrix in this situation but it is prudent to defer Shingrix until the patient's immune system has recovered from the treatment.
Can someone with hepatitis C receive zoster vaccine?
Hepatitis C infection is not a contraindication for Shingrix vaccination. However, if someone with hepatitis C is receiving a medication that can cause immunosuppression, they should consult with their healthcare provider and consider delaying vaccination with Shingrix until they have completed treatment.
Can a person age 60 years or older with a diagnosis of an autoimmune disease, such as lupus or rheumatoid arthritis, receive zoster vaccine?
Yes. Shingrix can be administered in this situation.
A 65-year-old patient is having major back surgery next week. He is requesting zoster vaccine today. Can I give him the vaccine?
Yes. Shingrix can be administered in this situation.
We have a 61-year-old patient who is taking 500 mg of valacyclovir (Valtrex) daily. Can she receive zoster vaccine?
Acyclovir, famciclovir, and valacyclovir are antiviral drugs that are active against herpesviruses. These drugs will have no effect on Shingrix, which does not contain live varicella virus.
If my patient is taking Tamiflu (oseltamivir), can she receive zoster vaccine?
Yes. Although oseltamivir is an antiviral drug, it is only effective against influenza A and B viruses. Shingrix does not contain live virus and will not be affected by oseltamivir.
Administering Vaccines Back to top
How are zoster vaccines administered?
Reconstitute recombinant zoster vaccine (RZV, Shingrix, GSK) using only the adjuvant solution provided with the vaccine antigen. After reconstitution, administer Shingrix immediately by the intramuscular route or store the reconstituted vaccine refrigerated between 2° and 8°C (36° and 46°F) and use within 6 hours. Discard reconstituted vaccine if not used within 6 hours or if frozen. If Shingrix is reconstituted with other than the supplied adjuvant solution, it should be repeated. The dose can be repeated immediately. There is no interval that must be met between these doses.
A patient was inadvertently given Shingrix by the subcutaneous rather than the intramuscular route. Does the dose need to be repeated?
Shingrix has been shown to be immunogenic when given by the subcutaneous route. A dose erroneously given by this route does not need to be repeated.
When reconstituted, the volume of Shingrix is more than 0.5 mL. Should the entire volume of reconstituted vaccine be administered or just 0.5 mL as indicated in the package insert?
The Shingrix adjuvant solution may contain up to 0.75 mL of liquid. The entire volume of the adjuvant solution should be withdrawn and used to reconstitute the lyophilized vaccine. After mixing, withdraw the recommended dose of 0.5 mL. Discard any reconstituted vaccine left in the vial.
Can pharmacists in all states administer zoster vaccine?
According to the American Pharmacist Association, all states allow pharmacists to administer zoster vaccine. Not all pharmacists provide vaccination services, and of those who do, not all administer zoster vaccine. It is best to call the pharmacy ahead of time to find out if they have Shingrix to administer to your patients. The vaccine must be administered in the pharmacy. Do NOT instruct the patient to transport the vaccine from the pharmacy back to your office. This could damage the potency of the vaccine.
A 60-year-old patient was inadvertently given varicella vaccine instead of Shingrix. Should the patient still be given Shingrix? If so, how long an interval should occur between the 2 doses?
CDC recommends that if a provider mistakenly administers varicella vaccine to a person for whom zoster vaccine is indicated, no specific safety concerns exist, but the dose should not be considered valid. Shingrix should be administered at least 8 weeks after receipt of the varicella vaccine. However, if Shingrix is administered less than 8 weeks after the varicella vaccine, it does not need to be repeated. A second dose of Shingrix should be given 26 months after the first dose of Shingrix. Avoid such errors by checking the vial label 3 times to make sure you're administering the product you intended.
If Shingrix is erroneously given to a child for prevention of varicella, the dose is invalid, but is there a waiting period before a valid dose of varicella vaccine can be given? Is it OK to give a dose of varicella vaccine as soon as the error is discovered?
There is no waiting period. The varicella vaccine dose can be given at any time after the Shingrix dose.
We inadvertently gave a 47-year-old healthcare worker Shingrix rather than varicella vaccine for work. Does this dose count?
No. The Shingrix vaccine does not count as a vaccination against primary varicella infection (chickenpox). The first varicella vaccine dose can be given at any time after the Shingrix dose. The second dose of varicella vaccine should be given 4 to 8 weeks after the first dose. You should always check the label 3 times to ensure you are administering the product intended.
While giving a dose of Shingrix the syringe came loose from the needle and part of the dose was lost. Will the patient be protected with this partial dose or does it need to be repeated?
A dose less than the full 0.5 mL dose is not valid and should be repeated. If the patient is still in the office the dose can be repeated immediately. If the repeat dose cannot be given on the same day CDC recommends that it should be given 4 weeks after the invalid dose.
My medical assistant inadvertently administered a 0.5 mL dose of the Shingrix diluent only. The dose did not contain any antigen. When can we administer a properly reconstituted dose?
The CDC zoster subject matter experts recommend that in this situation you should wait 4 weeks before giving a repeat dose.
Several doses (antigen and diluent) of Shingrix were mistakenly stored in our office freezer. One of these doses was administered to a patient. Is this dose valid and if not, when can it be repeated?
Any Shingrix, either antigen or diluent, that is exposed to freezing temperature should not be used. If a dose exposed to freezing temperature is given to a patient the dose should be considered invalid and should be repeated 4 weeks after the invalid dose.
Storage and Handling Back to top
How should Shingrix be stored?
Both lyophilized Shingrix and the adjuvant solution diluent must be stored at refrigerator temperature, between 2° and 8°C (between 36° and 46°F). Protect the vials from light. Do not freeze. Vaccine or adjuvant solution that has been frozen must be discarded. If vaccine that was frozen was administered, the dose does not count and should be repeated. The repeat dose should be administered 4 weeks after the frozen dose. After reconstitution, administer Shingrix immediately or store refrigerated between 2° and 8°C (between 36° and 46°F) and use within 6 hours. Discard reconstituted vaccine if not used within 6 hours.
How should Shingrix be transported to an off-site clinic location?
Shingrix is stored at refrigerator temperature. Transport of refrigerated vaccines is described in detail in the CDC Storage and Handling Toolkit, available at www.cdc.gov/vaccines/hcp/admin/storage/toolkit/storage-handling-toolkit-2020.pdf, pages 22–24. Providers should also review the vaccine package inserts for the specific vaccines being transported.
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This page was updated on October 22, 2020.
This page was reviewed on October 3, 2020.
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